Rehabilitation Center Program

PURPOSE: This rule establishes the regulatory basis for the administration of the rehabilitation center program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available through the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services, and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria and methodology for provider reimbursement, participant eligibility, and amount, duration, and scope of services covered are included in the rehabilitation center provider manual which is available at the website dss.mo.gov/mhd. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet rehabilitation center program shall be administered by the Department of Social Services, MO HealthNet Division. The rehabilitation center services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the rehabilitation center provider manual, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, and at its website at http://manuals.momed.com/collections/collection_reh/pr int.pdf, November 24, 2020. This rule does not incorporate any subsequent amendments or additions. Rehabilitation center services shall include only those that are clearly shown to be medically necessary as determined by the treating physician. The division reserves the right to effect changes in services, limitations, and fees with notification to rehabilitation center providers by amending this rule. (2) Persons Eligible. The MO HealthNet Rehabilitation Program pays for the adaptive training of MO HealthNet participants who receive a prosthetic/orthotic device. In addition, rehabilitation centers may provide physical, occupational, and speech therapy to children under the age of twenty-one (21) when medically necessary as determined by the treating physician. The Omnibus Reconciliation Act of 1989 (OBRA-89) mandated that MO HealthNet covered services be provided based on medical necessity as determined by the treating physician in a healthy children and youth screening. The participant must be eligible on the date service is furnished. Participants may have specific limitations to rehabilitation center program services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on his or her type of assistance as outlined in the rehabilitation center provider manual. The provider shall ascertain the patient’s MO HealthNet/MO HealthNet Managed Care status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the rehabilitation center provider manual. (3) Provider Participation. (A) To be eligible for participation in the MO HealthNet rehabilitation center program, a provider must meet the criteria specified for his or her profession as outlined in the rehabilitation center provider manual and be an enrolled MO HealthNet provider. (B) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request, furnish to the Department of Social Services or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan. (4) Covered Services. The participant shall have a referral for speech therapy services from a MO HealthNet enrolled primary care provider. The participant shall have a prescription for occupational and physical therapy services from a MO HealthNet enrolled primary care provider. (5) Reimbursement. Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for rehabilitation center services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charges. Rehabilitation services are only payable to an enrolled, eligible, participating provider. (6) Documentation. For physical, occupational, and speech therapy services, the MO HealthNet Division requires that the following documentation be included in the participant’s record: (A) Participant’s complete name; (B) Date the service was provided; (C) Actual treatment provided for the participant (more than “treatment given”) on the specific date of service; (D) Individual or group therapy (the provider must document the type of therapy given); (E) The time the service was delivered must be clearly documented in the client record (e.g., 4:00–4:15 p.m.); providers cannot bill for charting time, only the time they spend doing the therapy; (F) The signature of the therapist who provided the service; and (G) The official Individual Education Plan (IEP) or Individual Family Services Plan (IFSP) which must be in the record when billing therapy with a TM or TR modifier. (7) Records Retention. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with, and fully document, services billed to the MO HealthNet Division. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016.* Original rule filed Nov. 1, 2002, effective April 30, 2003. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Jan. 10, 2022, effective July 30, 2022. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.